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No More Democrats OR Republicans: A Simple Plan to Dismantle the Two-Party System

Revolutions are built on a simple idea. Mine is for all Americans, one by one, to leave the two-party system and become independent voters. We might not all agree on which politician is best for any given office, but we can all agree that every politician is made worse by the two-party system. So let¶s at least get rid of that.

The power of the two major political parties is derived from their memberships. If they have no members then they no longer exist. Everyone currently registered as a Democrat or a Republican ± about 70% of the electorate collectively controls the fate of the two-party system. You can dismantle it at anytime simply by becoming an independent voter.

Regardless of political leanings, all Americans like freedom: in our professional lives, our political lives, and our personal lives. The historical record consistently demonstrates that we have rarely settled for less; standing

vigilant time and time again against any and all violations of freedom.

On the surface, the two-party system looks like an elegant protector of the freedom we cherish, a balanced structure where Democrats and Republicans trade power about equally. Dig a little deeper and you find that the two-party system itself has become more powerful than its component parts. By cozying up to big business and passing laws that effectively close the political process to outsiders, the Democrats and Republicans dampen the influence of individual voters while ensuring the collective power of their two-party system, no matter which one of the parties is ruling.

The United States government has three primary tasks: make laws, enforce laws, and spend tax dollars; and three branches with which to accomplish these tasks: the legislative, the judicial, and the executive. Thanks to the system of checks and balances all three branches participate in all three tasks; but roughly speaking the legislative branch makes the laws and spends the taxes, the executive branch enforces the laws and blesses the taxspending ideas, and the judicial branch decides what to do

when someone breaks one (or more) of the laws. This whole apparatus, as elegantly outlined in The United States Constitution, works pretty well.

The modern two-party political system was an afterthought, a mutation affixed to our nation more than a half century after The Constitution was signed. For the first fifty years of its life, America essentially had one political group, ironically named the Democratic Republicans. Led by Thomas Jefferson, the Democratic Republicans dominated the political landscape well into the early 1800¶s. Jefferson co-authored The Declaration of Independence and once famously said, ³If I could not go to heaven but with a party, I would not go there at all.´

In the 1820¶s, despite Jefferson¶s sentiments, the Democratic Republican party began to split over the issue of whether the United States should have a national bank or an independent treasury, evidently a white-hot issue at the time. Proponents of the national bank called themselves National Republicans and proponents of the independent treasury took the name Democrat. Andrew Jackson, the first leader of the Democrats and the father of the modern Democratic Party, was elected President in 1828 and again

in 1832. In 1836, the National Republicans changed their name to the Whigs (a clear branding error) and ran William Henry Harrison against Martin Van Buren. Van Buren won the election and the Democrats remained in control for another four years.

Harrison finally won for the Whigs in 1840. James Polk won for the Democrats in 1844, and then Zachary Taylor wrested control back for the Whigs in 1848. The Whig party began to split in 1852 over the issue of slavery. During the next few years most southern Whigs joined the pro-slavery Democrats while most Northern Whigs joined the anti-slavery Democrats to form a new party, which took the name Republican. Lead by Abraham Lincoln, the Republicans won the election in 1860. And so goes the rough history of how we ended up where we are.

Since the end of the American Civil War the two modern political parties - Democrats and Republicans ± have waged a war on the influence of the individual voter by instituting election processes and regulations - the primary system, the winner-take-all philosophy of the Electoral College, and campaign finance regulation - that build the power of the two-party system at the expense of

the individual voter. We don¶t need a nation of strict Constitutionalists, but it¶s good to know what the original plan was. The two-party system was not part of the original plan.

Both Democrats and Republicans are pretty bad, particularly right now. But it¶s the two-party system that is failing us more than either party. We need to re-shape the basic legislative environment to make all politicians more effective. A good start is dismantling the two-party system.

All it takes to accomplish this is one simple act that carries little risk and no expense: become an independent voter. Without the baggage of a party affiliation, you will be free to think independently. And without any members, the Democratic and Republican parties won¶t exist; and the two-party system will be dismantled.

If one-by-one we all become independent voters, the Democratic and Republican parties will lose their monolithic structures and take on different roles, perhaps alongside the many other legislative think tanks that populate the political landscape, all of which would then

be contributing to a more rich and healthy political dialogue. Once the clear majority of us are independent voters, most politicians and candidates will abandon their party affiliation and become independent themselves. Becoming independent voters is one simple step we can all take back toward the independent thinking on which our country was founded and with which it has flourished for so long.

Below are some links to help you take action right now and switch your voter registration to independent.

Click here for a voter registration form. This is the same form you would use to register as a new voter. It¶s also used to switch your registration status to independent.

Click here for your state¶s specific instructions for filling out this form.

Here is a PDF of the whole package if you¶d like to make it available from your blog, Facebook page, etc.

Becoming an independent voter is easy. The correct form is provided here. Simply print the form, fill it out, place it in an envelope, address the envelope to your appropriate state office, and drop it in the mail. You will find the address for your state office in the instructions for your specific. You can also deliver the form in person to your local voter registration office.

Two important notes:

1. To become an independent voter you must leave box #7 blank.

2. It is ok to submit this form even if you are already registered to vote and affiliated with a party. If you are currently registered to vote the U.S. government will automatically view this form as you changing your existing party affiliation to become an independent voter. But remember to leave box #7 blank!

To use this form, you must be a U.S. citizen who lives in or has an address within the United States and you must be eighteen years old. You cannot use this form if you live

outside the U.S. and its territories, have no home address in the U.S., or are in the U.S. military stationed abroad.

If you are using this form to register to vote for the first time, Federal law requires you to show proof of identification, either sent along with this form or shown in person the first time you vote. Proof of identification includes a current and valid photo I.D or a current utility bill, bank statement, government check, or other government document that shows your name and address. If you choose to include a proof of identification with this form make sure you use a copy. Do not send an original document. You can also elect to bring identification with you the first time you vote.

Alabama

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 ² ID Number Drivers license number or last four digits of your social security number. Box 7 ² Choice of Party To become an independent voter simply leave this box blank. Box 8 ² Race or Ethnic Group Leave blank Box 9 ² Signature To register in Alabama you must:  be a resident of Alabama and your county  not have been convicted of a felony punishable by imprisonment in the penitentiary (or have had your civil and political rights restored)  not currently be declared mentally incompetent through a competency hearing  swear or affirm to support and defend the Constitution of U.S. and the State of Alabama and further disavow any belief or affiliation with any group which advocates the overthrow of the governments of the U.S. or the State of Alabama by unlawful means and that the information contained herein is trust, so help me God. Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant.

Alaska

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank

Box 9 - Signature To register in Alaska you must:  be a resident of Alaska  not be a convicted felon (unless unconditionally discharged)  not be registered to vote in another State Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address:

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Arizona you must:  be a resident of Arizona and your county at least 29 days preceding the next election  not have been convicted of treason or a felony (or have had your civil rights restored)  not currently be declared an incapacitated person by a court of law Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Secretary of State/Elections 1700 W. Washington, 7th Floor Phoenix, AZ 85007-2888

Arkansas

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Arkansas you must:  be a resident of Arkansas and your county at least 30 days preceding the next election  not have been convicted of treason or a felony (or have had your civil rights restored)  not claim the right to vote in any other jurisdiction  not previously be adjudged mentally incompetent by a court of competent jurisdiction Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Secretary of State Voter Services P.O Box 8111 Little Rock, AR 72203-8111

California

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in California you must:  be a resident of California at least 15 days preceding the next election  not be imprisoned or on parole for the conviction of a felony  not currently be judged mentally incompetent by a court of law Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Secretary of State Elections Division 1500 11th Street Sacramento, CA 95814

Colorado

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Colorado you must:  be a resident of Colorado at least 30 days preceding the next election  not be confined as a prisoner or serving any part of s sentence under mandate Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Colorado Secretary of State 1700 Broadway, Suite 270 Denver, CO 80290

Connecticut

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Connecticut you must:  be a resident of Connecticut and of the town in which you wish to vote  have completed confinement and parole if previously convicted of a felony, and have had your voting rights restored by Registrars of Voters  not currently be declared mentally incompetent to vote by a court of law Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Secretary of State Elections Division 30 Trinity Street Hartford, CT 06106

Delaware

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Delaware you must:  be a permanent resident of Delaware and of the town in which you wish to vote  felons are eligible to vote if certain requirements are met: fines and sentence completed at least five years prior to application date; felony convictions can not be disqualifying felonies, which are murder, sexual offenses, or crimes against public administration involving bribery or improper influence or abuse of office  not currently be mentally incompetent Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Commissioner of Elections 111 S. West St., Suite 10 Dover, DE 19904

District of Columbia

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in the District of Columbia you must:  be a resident of the District of Columbia  not be in jail for a felony conviction  not have been judged ³mentally incompetent´ by a court of law  not claim the right to vote anywhere outside D.C. Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: District of Columbia Board of Elections and Ethics 441 4th Street, NW, Suite 250 Washington, DC 20001-2745

Florida

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Florida you must:  be a legal resident of both the state of Florida and of the county in which you seek to be registered  not now be adjudicated mentally incapacitated with respect to voting in Florida or any other state  not have been convicted of a felony without your civil rights having been restored pursuant to law  not claim the right to vote in another county or state  swear or affirm the following ³I will protect and defend Constitution of the United States and the Constitution of the State of Florida, that I am qualified to register as an elector under the Constitution and laws of the State of Florida, and that I am a citizen of the United States and a legal resident of Florida.´ Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: State of Florida Department of State Division of Election

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Georgia you must:  be a legal resident of Georgia and of the county in which you want to vote  not have been judicially determined to be mentally incompetent unless the disability has been removed  not be serving a sentence for having been convicted of a felony Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Elections Division Office of the Secretary of State 1104 West Tower 2 Martin Luther King, Jr. Dr. SE Atlanta, Georgia 30334-1505

Hawaii

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Hawaii you must:  be a resident of the State of Hawaii Georgia and of the county in which you want to vote  not be adjudicated by a court as mentally incompetent  not be incarcerated for a felony conviction Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Office of Elections State of Hawaii 802 Lethua Avenue Pearl City, HI 96782

Idaho

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Idaho you must:  have resided in Idaho and in the county for 30 days prior to the day of election  not have been convicted of a felony, and without having been restored to the rights of citizenship, or confined in prison on conviction of a criminal offense Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Secretary of State P.O Box 83720 State Capitol Bldg. Boise, ID 83720-0080

Illinois

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Idaho you must:  be a resident of Illinois and of your election precinct at least 30 days before the next election  not be in jail for a felony conviction  not claim the right to vote anywhere else Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: State Board of Elections 1020 S. Spring Street Springfield, IL 62704

Indiana

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Indiana you must:  have resided in the precinct at least 30 days before the next election  not currently be in jail for a criminal conviction  Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Election Division Office of the Secretary of State 302 West Washington Street Room E-204 Indianapolis, IN 46204-2743

Iowa

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Iowa you must:  be a resident of Iowa  not have been convicted of a felony (or have had your rights restored)  not currently be a judged by a court to be ³incompetent to vote´  not claim the right to vote in more than one place  give up your right to vote in any other place Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Elections Division Office of the Secretary of State Lucas Building ± 1st Floor 321 E. 12th Street Des Moines, IA 50319

Kansas

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Kansas you must:  be a resident of Kansas  have completed the terms of your sentence if convicted of a felony  not be excluded from voting for mental incompetence by a court of competent jurisdiction  not claim the right to vote in any other location or under any other name Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Secretary of State 1st Floor, Memorial Hall 120 SW 10th Ave. Topeka, KS 66612-1594

Kentucky

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Kentucky you must:  be a resident of Kentucky and the county  not be a convicted felon or if you have been convicted of a felony, your civil rights have been restored by executive pardon  not have been judged ³mentally incompetent´ in a court of law  not claim the right to vote anywhere outside Kentucky Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: State Board of Elections 140 Walnut Street Frankfort, KY 40601-3240

Louisiana

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Louisiana you must:  be a resident of Louisiana and resident address must be address where you claim homestead exemption, if any  not currently be under an order of imprisonment for conviction of a felony  not currently be under a judgment of interdiction for mental incompetence Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Secretary of State Attention: Voter Registration P.O. Box 94125 Baton Rouge, LA 70804-9125

Maine

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Maine you must:  be a resident of Maine and the municipality in which you want to vote Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Elections Division Bureau of Corporations, Elections and Commissions 101 State House Station Augusta, ME 04333-0101

Maryland

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Maryland you must:  be a resident of Maryland  not have been convicted of buying or selling votes  not have been convicted of a felony, or if you have, you have completed serving a court ordered sentence of imprisonment, including any term of parole or probation for the conviction  not be under guardianship for mental disability Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: State Board of Elections P.O. Box 6486 Annapolis, MD 21401-0486

Massachusetts

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Massachusetts you must:  be a resident of Massachusetts  not have been convicted of corrupt practices in respect to elections  not be currently incarcerated for a felony conviction  not be under guardianship with respect to voting Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Secretary of the Commonwealth Elections Division, Room 1705 One Ashburton Place Boston, MA 02108

Michigan

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Michigan you must:  be a resident of Michigan and at least a 30-day resident of your city or township by election day  not be confined in jail after being convicted and sentenced Caution: If you register by mail, you must vote in person at your assigned precinct the first time you vote, unless you are: disabled as defined by state law; 60 years of age or older; or temporarily residing overseas Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Michigan Department of State Bureau of Elections P.O. Box 20126 Lansing, MI 48901-0726

Minnesota

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Minnesota you must:  be a resident of Minnesota for 20 days before the election  maintain residence at the address given on the registration form  if previously convicted of a felony, your felony sentence has expired or been completed, or you have been discharged from the sentence  not be under court-ordered guardianship in which the right to vote has been revoked  not be found by a court to be legally incompetent to vote Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Secretary of State 60 Empire Drive, Suite 100 St. Paul, MN 55103-1855

Mississippi

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Mississippi you must:  have lived in Mississippi and in your county (and city, if applicable) 30 days before the election  not have been convicted of murder, rape, bribery, theft, arson, obtaining money or stolen good under false pretense, perjury, forgery, embezzlement, armed robbery, extortion, felony bad check felony shoplifting, larceny, receiving stolen property, robbery, timber larceny, unlawful taking of a motor vehicle, statutory rape, carjacking, or bigamy, or have had your rights restored as required by law  not have been declared mentally incompetent to vote Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Secretary of State P.O. Box 136 Jackson, MS 39205-0136

Missouri

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Missouri you must:  be a resident of Missouri  not be on probation or parole after conviction of a felony, until finally discharged from such probation or parole  not be convicted of a felony or misdemeanor connected with the right of suffrage  not be adjudged incapacitated by any court of law  not be confined under a sentence of imprisonment Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Secretary of State P.O. Box 1767 Jefferson City, MO 65102-1767

Montana

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Montana you must:  be a resident of Montana and in the county in which you want to vote for at least 30 days before the election  not be in a penal institution for a felony conviction  not currently be determined by a court to be of unsound mind  meet these qualifications by the next election day if you do not currently meet them Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Secretary of State¶s Office P.O. Box 202801 State Capitol Helena, MT 59620-2801

Nebraska

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Montana you must:  be a resident of Nebraska  not have been convicted of a felony, or if convicted, have had your rights restored  not have been officially found to be mentally incompetent Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Nebraska Secretary of State Suite 2300, State Capitol Bldg. Lincoln, NE 68509-4608

Nevada

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Nevada you must:  have continuously resided in the State of Nevada, in your county, at least 30 days and in your precinct at least 10 days before the election  have your civil rights restored if you were convicted of a felony  not be determined by a court of law to be mentally incompetent  claim no other place as your legal residence Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Secretary of State Elections Division 101 North Carson Street Suite 3 Carson City, NV 89701-4786

New Hampshire

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. New Hampshire town and city clerks will accept this application only as a request for their own absentee voter mail in registration form. You need to fill in only Box 1 and Box 2 or 3. The application should be mailed to your town or city clerk at your zip code. These addresses are listed on the Secretary of State web site at http://www.state. nh.us/sos/clerks.htm It should be mailed in plenty of time for your town or city clerk to mail you their own form and for you to return that form to them by 10 days before the election. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show

where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail.

New Jersey

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in New Jersey you must:  be a resident of New Jersey and your county at your address at least 30 days before the election  not be serving a sentence or on parole or probation as the result of a conviction of any indictable offense under the laws of this or another state or of the United States Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: New Jersey Department of Law and Public Safety Division of Elections PO Box 304 Trenton, NJ 08625-0304

New Mexico

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in New Mexico you must:  be a resident of the State of New Mexico  not have been denied the right to vote by a court of law by reason of mental incapacity and, if I have been convicted of a felony, I have completed all conditions of probation or parole, served the entirety of a sentence or have been granted a pardon by the Governor Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Bureau of Elections 325 Don Gaspar, Suite 300 Sante Fe, NM 87503

New York

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in New York you must:  be a resident of the county or of the City of New York, at least 30 days before the election  not be in jail or on parole for a felony conviction  not currently be judged incompetent by order of a court of competent judicial authority  not claim the right to vote elsewhere Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: NYS Board of Elections 40 Steuben Street Albany, NY 12207-2108

North Carolina

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in North Carolina you must:  be a resident of North Carolina and the county in which you live for at least 30 days prior to the election  have your rights of citizenship restored if you have been convicted of a felony  not be registered or vote in any other county or state Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: State Board of Elections P.O. Box 27255 Raleigh, NC 27611-7255

North Dakota

North Dakota does not have voter registration.

Ohio

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Ohio you must:  be a resident of Ohio  not be convicted of a felony or currently incarcerated  not be found incompetent by a court for purposes of voting Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Secretary of State of Ohio Elections Division 180 E. Broad Street ± 15th Floor Columbus, Ohio 43215

Oklahoma

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Oklahoma you must:  be a resident of Oklahoma  have not been convicted of a felony , for which a period of time equal to the original sentence has not expired, or for which you have not been pardoned  not now be under judgment as an incapacitated person or a partially incapacitated person prohibited from registering to vote Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Oklahoma State Election Board Box 528800 Oklahoma City, OK 73152-8800

Oregon

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Oklahoma you must:  be a resident of Oregon Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Secretary Elections 141 State Salem, OR of State Division Capitol 97310-0722

Pennsylvania

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Pennsylvania you must:  be a resident of Pennsylvania and your election district at least 30 days before the election Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Office of the Secretary of the Commonwealth 210 North Office Bldg. Harrisburg, PA 17120-0029

Rhode Island

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Rhode Island you must:  be a resident of Rhode Island for 30 days preceding the election  not be currently incarcerated in a correctional facility due to a felony conviction  not have been lawfully judged to be mentally incompetent Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Rhode Island State Board of Elections 50 Branch Ave. Providence, RI 02904-2790

South Carolina

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in South Carolina you must:  be a resident of South Carolina, your county and your precinct  not be confined in any public prison resulting from a conviction of a crime  never have been convicted of a felony or offence against the election laws, or if previously convicted, have served your entire sentence, including probation or parole, or have received a pardon for the conviction  not be under court order declaring you mentally incompetent  claim the address on the application as your only legal place of residence and claim no other place as your legal residence Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: State Election Commission P.O. Box 5987 Columbia, SC 29250-5987

South Dakota

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in South Dakota you must:  be a resident of South Dakota  not be a sentence for a felony conviction which imprisonment, served or suspended, in an system  not have been adjudged mentally court currently serving included adult penitentiary incompetent by a

Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Elections, Secretary of State 500 E. Capitol Pierre, SD 57501-5070

Tennessee

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Tennessee you must:  be a resident of Tennessee  not have been convicted of a felony, or if convicted, have had your full rights of citizenship restored (or have received a pardon)  not be adjudicated incompetent by a court of competent jurisdiction (or have been restored to legal capacity) Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Coordinator of Elections Tennessee Tower, Ninth Floor 312 Eighth Avenue, North Nashville, TN 37243

Texas

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Texas you must:  be a resident of the county in which the application for registration is made  not be finally convicted of a felony, or if a convicted felon, you must have fully discharged your punishment, including any incarceration, parole, supervision, period of probation or be pardoned  not have been declared mentally incompetent by final judgment of a court of law Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Office of the Secretary of State Elections Division P.O Box 12060 Austin, TX 78711-2060

Utah

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Utah you must:  have resided in Utah for 30 days immediately before the next election  not be a convicted felon currently incarcerated for commission of a felony  not be convicted of treason or crime against the elective franchise, unless restored to civil rights  not be found to be mentally incompetent by a court of law Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Office of the Lieutenant Governor P.O Box 142325 Salt Lake City, UT 84114

Vermont

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Vermont you must:  be a resident of Vermont  have taken the following Oath: You solemnly swear (or affirm) that whenever you give your vote or suffrage, touching any matter that concerns the state of Vermont, you will do it so as in your conscience you shall judge will most conduce to the best good of the same, as established by the Constitution, without fear or favor of any person [Voter¶s Oath, Vermont Constitution, Chapter II, Section 42]. By signing in Box 9, you are attesting that you have sworn or affirmed the Vermont voter¶s oath as printed above. Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Office of the Secretary of State Director of Elections 26 Terrace Street Montpelier, VT 05609-1101

Virginia

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Virginia you must:  be a resident of Virginia and of the precinct in which you want to vote  not have been convicted of a felony, or have had your civil rights restored  not currently be declared mentally incompetent by a court of law Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: State Board of Elections 1100 Bank Street, 1st Floor Richmond, VA 23219

Washington

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Washington you must:  be a legal resident of Washington State, your county and precinct for 30 days immediately preceding the election in which you want to vote  not be convicted of infamous crime, unless restored to civil rights Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Secretary of State Voter Registration by Mail P.O. Box 40230 Olympia, WA 98504-0230

West Virginia

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in West Virginia you must:  live in West Virginia at the above address  not be under conviction, probation, or parole for any felony, treason, or election bribery  not have been judged ³mentally incompetent´ in a court of competent jurisdiction Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: Secretary of State Building 1, Suite 157-K 1900 Kanawha Blvd. East Charleston, WV 25305-0770

Wisconsin

Before filling out the body of the form, please answer the questions on the top of the form as to whether you are a United States citizen and whether you will be 18 years old on or before Election Day. If you answer no to either of these questions, you may not use this form to register to vote. Box 1 ² Name Put in this box your full name in this order ² Last, First, Middle. Do not use nicknames or initials. Note: If this application is for a change of name, please tell us in Box A (on the bottom half of the form) your full name before you changed it. Box 2 ² Home Address Put in this box your home address (legal address). Do not put your mailing address here if it is different from your home address. Do not use a post office box or rural route without a box number. Note: If you were registered before but this is the first time you are registering from the address in Box 2, please tell us in Box B (on the bottom half of the form) the address where you were registered before. Please give us as much of the address as you can remember. Also Note: If you live in a rural area but do not have a street address, or if you have no address, please show where you live using the map in Box C (at the bottom of the form). Box 3 ² Mailing Address If you get your mail at an address that is different from the address in Box 2, put your mailing address in this box. If you have no address in Box 2, you must write in Box 3 an address where you can be reached by mail. Box 4 ² Date of Birth Put in this box your date of birth in this order ² Month, Day, Year. Be careful not to use today¶s date!

Box 5 ² Telephone Number Put in this box your phone number. If you don¶t have one or do and don¶t wish to share it, you do not have to fill in this box. Box 6 - ID Number Drivers license number or last four digits of your social security number. Box 7 - Choice of Party To become an independent voter simply leave this box blank. Box 8 - Race or Ethnic Group Leave blank. 9. Signature To register in Wisconsin you must:  been a resident of Wisconsin for at least 10 days  not have been convicted of treason, felony or bribery, or if you have, your civil rights have been restored  not have been found by a court to be incapable of understanding the objective of the electoral process  not make or benefit from a bet or wage depending on the result of an election  not have voted at any other location, if registering on election day Sign your full name or make your mark, and print today¶s date in this order ² Month, Day, Year. If the applicant is unable to sign, put in Box D the name, address, and telephone number (optional) of the person who helped the applicant. Mailing address: State Elections Board 17 West Main Street, Suite 310 P.O. Box 2973 Madison, WI 53701-2973

AMERICA IS BROKEN: Here's How You Can Use Your Vote To Fix It

Description

More Americans consider themselves independent than either Democrat or Republican and the majority of Americans work for a small business. Despite this America is controlled by a two-party politica...

More Americans consider themselves independent than either Democrat or Republican and the majority of Americans work for a small business. Despite this America is controlled by a two-party political system – with Democrats on one side and Republicans on the other – that is itself controlled by big business.